Summary Report for Family Support Plan Service Authorizations (FSPSAs) Overlapping the Report Period Center: 07
This report estimates subtotals of units and fees for the number of days of overlap between each included
FSPSA record and the user-selected report period. For example, if the FSPSA record authorizes services from
01/01/01 to 08/01/01, and the Report Period is selected as 01/01/01 to 03/01/01, this summary calculates
authorized units/fees for the 28 days of overlap (02/01/01 to 03/01/01). Note that service authorization periods
may range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs overlapping: 01/01/08 and 12/31/08 Date of Report: 02-16-09 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Fees Avg Fee
Children Records Overlapping Overlapping Per Unit Auth
Report Period Report Period
Service Coordination, Class # 01
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 4.07 $150.47 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.02 $74.82 $37.00
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Subtotal (Total Children Is Unduplicated) 3 3 6.09 $225.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.00 $108.21 $36.07
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.00 $17.66 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.00 $10.80 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.00 $21.79 $21.79
AUDE -AUDE UNSPECIFIED AUDE SERVICES 7 7 7.00 $420.00 $60.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 9 10 148.00 $18500.03 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 13 13 16.01 $800.56 $50.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.81 $156.02 $55.50
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.50 $262.50 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 15.00 $832.50 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 122 177 286.63 $21497.51 $75.00
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.77 $88.34 $50.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 10.23 $496.32 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 99 107 96.89 $4699.38 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 18 18 21.97 $1065.61 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 108 127 153.42 $7440.67 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 1 1 1.00 $50.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 253 287 266.63 $12931.71 $48.50
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Subtotal (Total Children Is Unduplicated) 458 786 1044.87 $69865.87 $66.87
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.00 $9000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 5 5 5.00 $250.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 22 42.15 $2107.34 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 4 4.90 $122.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 25 28 49.50 $2475.18 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 2 2 6.20 $155.00 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 26 55.18 $2758.93 $50.00
CONOP -CONOP CONSULT, OT, PHONE 5 5 14.28 $357.08 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 32 79.56 $3978.09 $50.00
CONPP -CONPP CONSULT, PT, PHONE 4 5 14.69 $367.29 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 22 29 69.81 $3490.41 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 9 11 25.78 $644.49 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 19 27 1878.00 $23475.00 $12.50
EIGF -T1024TTHN *EI GROUP SESSION BY PROF 1 1 3.29 $82.14 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 19.57 $489.29 $25.00
EIIF -T1024HN *EI INDIVIDUAL SESSION BY PROF 143 143 1115.62 $55781.06 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 2 3 57.14 $1428.57 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 526 770 11490.35 $574517.70 $50.00
HERN -T1024HN *EI HEARING SERVICES AFTER SHINE 4 4 82.29 $4114.29 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 17 21 331.63 $16581.43 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 107 137 2032.40 $137959.02 $67.88
OCCT -97530HM OT SESSION BY OT ASST 71 84 1173.15 $63725.65 $54.32
PHY -97110 PT SESSION BY LICENSED PT 154 218 3572.94 $242531.09 $67.88
PHY -97110HM PT SESSION BY PT ASST 93 119 1749.93 $95055.96 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 19 21 26.86 $26.86 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 1 1 1.00 $500.00 $500.00
SENS -V5264 EARMOLD 3 3 5.78 $108.16 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 2 2 2.00 $100.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 308 426 6252.56 $424423.48 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 69.71 $3786.88 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 162 196 2923.34 $38588.05 $13.20
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 2 2 39.00 $19.50 $0.50
VISN -T1024HN *EI VISION SERVICES, INDIVIDUAL 3 3 29.00 $1450.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 6 6 58.68 $2934.17 $50.00
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Subtotal (Total Children Is Unduplicated) 999 2371 33288.29 $1715034.60 $51.52
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Total 3160 34339.25 $1785125.76 $51.99
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Number of Children (Unduplicated) With at Least One Authorization 1054